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Patients - Application for Antibiotic (restricted use)

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What is your birth sex? *

What antibiotic treatment are you looking for? *

Describe symptoms of illness (be as detailed as possible) *

Do you have any conditions affecting your heart or circulation including heart attacks, angina (chest pain), heart failure, a stroke or mini stroke, or claudication (cramping pain in yours legs when you walk)? *

Are you currently or in the last two months have you taken any medicine (prescribed or not), alternative medicines or recreational drugs? *

Do you have any sensitivity to medicines or any allergies (Penicillin Allergy?)? *

Other than conditions mentioned above, do you have any other significant medical conditions, illnesses or past surgical procedures?

I confirm that I have read and understood this and my answers are fully correct and true. *

I confirm and agree that any treatment prescribed for me is for my personal use only. *